Week 2: Ilustrated Atlas of Medication Administration

Repercussions for Administering the Wrong Medication in California

Administering the wrong medication is a serious error that can have significant repercussions for nurses in California

• “CA is a non-compact state b/c everyone wants to work in CA and it makes it harder for people to come here”

Legal and Professional Consequences: Disciplinary Action by the Board of Nursing

The California Board of Registered Nursing (BRN) may take disciplinary action against the nurse’s license, which can include:

• Reprimand

• Probation

• Suspension

• Revocation of the nursing license

Legal and Professional Consequences: Incident Reporting

• Nurses are required to complete an incident report to document the error and identify the root cause

• The purpose of the incident report is to improve patient safety and prevent future errors

  • “only an internal document, won’t be shared, can’t be subpoena’d”

Employment Consequences

Employer Actions:

• The healthcare facility may take additional actions, such as:

  • Mandatory retraining or education

  • Reassignment to different duties

  • Termination of employment

Legal Liability: Civil Liability

The nurse may face civil lawsuits from patients or their families for damages resulting from the medication error

Legal Liability: Criminal Liability

In severe cases, especially if the error results in significant harm or death, the nurse may face criminal charges

Ethical Considerations

• Patient autonomy and informed consent

• Beneficence and non-maleficence

  • “Beneficence = the ethical principle and practice of doing good, involving acts of kindness, charity, and actively helping others or promoting their welfare”

  • “Non-maleficence = the ethical principle of "do no harm," obligating individuals, especially healthcare professionals, to avoid intentionally causing injury, pain, or suffering to others”

• Confidentiality and privacy

• Professional integrity and accountability

• Advocacy for patient safety and well-being

Impact on Patient Safety

Medication errors can lead to serious patient harm, including adverse drug reactions, prolonged hospital stays, and even death

Impact on Trust

Such errors can damage the trust between patients and healthcare providers and harm the nurse’s professional reputation

Preventative Measures: Continuing Education

Nurses are encouraged to engage in continuing education to stay updated on best practices in medication administration

Preventative Measures: Adherence to Protocols

Strict adherence to medication administration protocols and double-checking procedures can help prevent errors

Unit Dose System

• Medications are individually packed and labeled for each dose

• Reduces medication errors

• Increases efficiency in medication administration

• Requires more storage space and inventory management

Automated Dispensing Cabinets (ADCs)

• Computerized cabinets that store and dispense medications

• Enhances security and tracking of medications

• Provides real-time inventory management

• Requires initial investment and maintenance costs

Centralized Pharmacy System

• Medications are prepared and dispensed from a central pharmacy

• Allows for specialized pharmacist oversight

• Reduces medication waste

• May cause delays in medication delivery to patients

Components of a Narcotic Control System

• Secure storage of narcotics (e.g., locked cabinets, safes)

• Strict inventory management and record-keeping

• Controlled access with authorized personnel only

• Regular audits and reconciliation of narcotic counts

• Reporting of discrepancies or theft to regulatory authorities

Common Types of Medication Errors

• Wrong medication or dose

• Incorrect route of administration

• Administration at the wrong time

  • “if this happens, call pharmacist to retime”

• Omission of a dose

• Failure to document administration

Actions to Prevent Medication Errors: “Eight Rights” of Medication Administration

• Right Patient

• Right Medication

• Right Dose

• Right Route

• Right Time

• Right Documentation

• Right Reason

• Right Response

Actions to Prevent Medication Errors

• Follow the “Eight Rights” of medication administration

• Use barcoding systems for verification

  • KBMA: Knowledge-based medication administration

• Double-check high-risk medications with another nurse

• Provide thorough education and training for staff

• Encourage a culture of safety and open communication about errors

Precautions for Ensuring the Right Drug is Given to the Right Patient

1. Verify patient identity using two identifiers (e.g., name, date of birth)

2. Confirm medication order and check for allergies

3. Use electronic health records (EHR) to cross-check patient information

4. Label medications clearly and double-check labels before administration

5. Educate patients about their medications and involve them in the verification process

Documentation of Medication Administration

• Record the name, dose, route, and time of administration

• Document any patient refusals or missed doses

• Note any adverse reactions or side effects

• Use standardized forms or electronic systems for consistency

Documentation of Medication Effectiveness

• Assess and document the patient’s response to the medication

• Record any changes in symptoms or vital signs

• Note the time frame for expected therapeutic effects

• Communicate findings to the healthcare team

“Know half-life and when to expect effects!”

Legal and Ethical Implications of Documentation

• Accurate documentation is a legal requirement and protects against liability

• Ensures continuity of care and supports clinical decision-making

• Reflects professional accountability and integrity

Summary and Best Practices of Medication Administration

• Adhere to legal and ethical guidelines for medication administration

• Utilize appropriate dispensing systems to enhance safety

• Implement a robust narcotic control system

• Take proactive measures to prevent medication errors

• Ensure accurate and thorough documentation of medication administration and effectiveness

Topical Medications

• Equipment needed:

  • Gloves

  • Applicators (e.g., cotton swabs, gauze pads)

  • Medication containers (e.g., tubes, jars)

• Techniques for application to the skin:

  • Cleaning the application site

  • Applying the medication evenly

  • Covering the area if necessary

Patch Testing

• Purpose of patch testing:

  • Identifying allergic reactions to substances

  • Diagnosing contact dermatitis

• Procedure for performing patch testing:

  • Selecting test substances

  • Applying patches to the skin

  • Monitoring and interpreting results

Nitroglycerin Ointment

• Equipment needed:

  • Applicator paper or measuring guide

  • Gloves

  • Ointment tube

• Sites and techniques for application:

  • Common sites (e.g., chest, upper arm)

  • Measuring the correct dose

  • Applying the ointment and covering with paper

• Patient education:

  • Importance of following dosage instructions

  • Possible side effects (e.g., headaches, dizziness)

  • Storage and handling of ointment

“main purpose is to prevent angina (chest pain) from coronary artery disease by relaxing and widening blood vessels, reducing the heart's workload”

Transdermal Patch Medication Systems

• Equipment needed:

  • Transdermal patches

  • Gloves

• Sites and techniques for application:

  • Common sites (e.g., upper arm, chest, back)

  • Cleaning the application site

  • Applying the patch and ensuring proper adhesion

• Patient education:

  • Importance of rotating application sites

  • Possible side effects (e.g., skin irritation)

  • Proper disposal of used patches

“Make sure patch is INTACT. NO CUTTING”

Medications to Mucous Membranes

• Dose forms:

  • Sprays, drops, gels, lozenges, suppositories

• Sites and equipment used:

  • Nasal passages, oral cavity, rectum, vagina

• Techniques for administration:

  • Proper positioning of the patient

  • Using applicators or fingers for insertion

Administering Eardrops

• Technique for patients less than 3 years old:

  • Pulling earlobe downward and back

• Technique for patients 3 years and older:

  • Pulling earlobe upward and back

Medications via Inhalation

• Purpose of inhalation medications:

  • Delivering medication directly to the lungs

  • Treating respiratory conditions (e.g., asthma, COPD)

• Precautions necessary:

  • Ensuring proper inhaler technique

  • Monitoring for adverse reactions (e.g., throat irritation)

• Patient education:

  • Demonstrating inhaler use

  • Importance of adherence to prescribed regimen

Administering Solid Forms of Oral Medications

• Verify patient identity and medication order

• Assess patient’s ability to swallow

• Explain the procedure to the patient

• Provide water or other fluids to aid swallowing

• Positioning the patient upright

• Placing the medication on the back of the tongue

• Encouraging the patient to drink water and swallow

• Monitor for adverse reactions

Administering Liquid-Form Oral Medications

• Verify patient identity and medication order

• Shake the medication bottle if required

• Measure the correct dose using appropriate tools (e.g., oral syringe, medicine cup)

• Explain the procedure to the patient

• Positioning the patient upright

• Administering the medication slowly to prevent choking

• Encouraging the patient to drink water after administration

Administering Medications via Gastrointestinal Tubes

• Equipment needed:

  • Gastrointestinal tube (e.g., NG tube, PEG tube)

  • Syringe, water, medication in liquid form or crushed tablets mixed with water

• Techniques:

  • Verifying tube placement before administration

  • Flushing the tube with water before and after medication administration

  • Administering each medication separately

• Precautions:

  • Preventing tube clogging by flushing with water

  • Monitoring for signs of aspiration or discomfort

Administering Rectal Suppositories

• Equipment needed:

  • Suppository, gloves, lubricant, disposable pad

• Technique:

  • Positioning the patient in Sims’ position

  • Lubricating the suppository and gloved finger

  • Inserting the suppository past the internal anal sphincter

Administering Disposable Enemas

• Equipment needed:

  • Disposable enema kit, gloves, lubricant, disposable pad

• Technique:

  • Positioning the patient in Sims’ position

  • Lubricating the enema nozzle

  • Inserting the nozzle into the rectum and administering the enema solution slowly

Safe Administration Practices for Parenteral Medications

• General Principles:

  • Verify patient identity and medication order

  • Use aseptic technique to prevent infection

  • Select appropriate injection site based on medication and patient factors

  • Rotate injection sites to prevent tissue damage

  • Dispose of needles and syringes safely

• Hand hygiene before and after administration

• Properly preparing the medication (e.g., reconstitution, mixing)

• Administering the medication at the correct angle (e.g., intramuscular, subcutaneous, intradermal)

• Monitoring for adverse reactions

  • “monitor the skin”

Angles and Administration for Parenteral Medications

• Intramuscular = 90°

  • Into muscle

  • Slower, sustained absorption

  • Common for vaccines (like flu shots) or hormones

• Subcutaneous = 45°

  • Into subcutaneous (fatty) tissue

  • Suitable for small volumes needing slow, sustained release (e.g., insulin, heparin)

• Intravenous = 25°

  • In the vein

  • Fastest effect

  • Often used for emergencies or large volumes

• Intradermal = 10-15°

  • Into the dermis

  • Slowest absorption rate

  • Often used for allergy testing or TB skin tests

Tuberculin Syringe vs. Larger-Volume Syringes

• Tuberculin Syringe

  • Volume capacity: up to 1 mL

  • Used for small doses (e.g., TB tests, vaccines)

  • Fine calibration for precise measurement

  • High precision, limited volume capacity

• Larger-Volume Syringe

  • Volume capacity: 2 mL to 60 mL

  • Used for larger doses (e.g., IV medications, irrigation)

  • Less precise calibration compared to tuberculin syringes

  • Greater volume capacity, less precision

Selecting the Correct Needle Gauge and Length

• Factors to Consider:

  • Type of medication (e.g., viscosity)

  • Injection site (e.g., muscle, subcutaneous tissue)

  • Patient factors (e.g., age, body size)

• Needle Gauge:

  • Smaller gauge number = larger needle diameter

  • Common gauges: 18G to 27G

• Needle Length:

  • Varies based on injection site and patient factors

  • Common lengths: ½ inch to 1.5 inches

“18G and 20G commonly used for blood or adults in acute care”

“22G and 23G commonly used in peds”

Needle Gauge Colors: 14G

Olive

Needle Gauge Colors: 15G

Amber

Needle Gauge Colors: 16G

Gray

Needle Gauge Colors: 18G

Green

Needle Gauge Colors: 20G

Pink

Needle Gauge Colors: 21G

Purple

Needle Gauge Colors: 22G

Blue

Needle Gauge Colors: 23G

Orange

Needle Gauge Colors: 25G

Red

Needle Gauge Colors: 27G

White

Advantages of Prefilled Syringes

• Convenience and time-saving

• Reduced risk of dosing errors

• Sterility and reduced contamination risk

Disadvantages of Prefilled Syringes

• Higher cost compared to vials

• Limited flexibility in dosing adjustments

• Potential for waste if full dose is not needed

Differentiating Ampules, Vials, and Mix-O-Vials

Ampules:

• Single-dose glass containers

• Require breaking the neck to access medication

Vials:

• Single-dose or multi-dose containers with rubber stoppers

• Require needle insertion to withdraw medication

• “Wipe top w/alcohol wipe for 10 seconds before administering”

Mix-O-Vials:

• Dual-chamber vials with separate compartments for diluent and medication

• Require mixing before administration

Preparing Two Different Drugs in One Syringe (e.g., Insulin)

• General Principles:

  • Verify compatibility of medications before mixing

  • Use aseptic technique to prevent contamination

• Techniques:

  • Draw air into the syringe equal to the dose of the first medication

  • Inject air into the vial of the first medication and withdraw the dose

  • Repeat the process for the second medication without expelling the first dose

Different IV Access Devices

• Peripheral IV catheters

• Central Venous Catheters (CVCs)

• Peripherally Inserted Central Catheters (PICCs)

• Implanted Ports

Peripheral IV Catheters

• Short-term use

• Inserted into peripheral veins (e.g., hand, arm)

Central Venous Catheters (CVCs)

• Long-term use

• Inserted into central veins (e.g., subclavian, jugular)

“not in our scope as nurses”

Peripherally Inserted Central Catheters (PICCs)

• Long-term use

• Inserted into peripheral veins and advanced to central veins

“Not in our scope of practice”

Implanted Ports

• Long-term use

• Surgically implanted under the skin

“less infection risk than PICCs”

Hypertonic Solutions

• Higher solute OUTSIDE

• Higher water INSIDE

• Water moves OUT

• Cell SHRINKS

Isotonic Solutions

• Equal solute

• Equal water

• No net movement

• Normal

Hypotonic Solutions

• Higher solute INSIDE

• Higher water OUTSIDE

• Water moves IN

• Cell SWELLS

Isotonic Solution in the Hospitals

• Same osmolarity as blood

• Examples: Normal saline (0.9% NaCl), Lactated Ringer’s

• Clinical uses: Fluid replacement, dehydration

Hypotonic Solution in the Hospitals

• Lower osmolarity than blood

• Examples: Half-normal saline (0.45% NaCl)

• Clinical uses: Cellular hydration, hypernatremia

Hypertonic Solution in the Hospitals

• Higher osmolarity than blood

• Examples: Dextrose 5% in normal saline (D5NS)

• Clinical uses: Electrolyte imbalances, hyponatremia

General Principles for Administering Medications via IV Route

1. Verify patient identity and medication order

2. Use aseptic technique to prevent infection

3. Select appropriate IV access device based on medication and patient factors

4. Monitor for adverse reactions during and after administration

Peripheral IV Line vs. Central IV Line

Peripheral IV Line

• Short-term use

• Inserted into peripheral veins

• Lower risk of complications

• Easier to insert, lower risk of infection, limited duration of use

Central IV Line

• Long-term use

• Inserted into central veins

• Higher risk of complications but allows for administration of irritant medications

• Allows for long-term use, administration of irritant medications, higher risk of infection

Administering Medications via Saline Lock, IV Bag, Infusion Pump, and Secondary Piggyback Set

Saline Lock:

• Flush with saline before and after medication administration

• Use aseptic technique to prevent infection

IV Bag:

• Verify medication order and patient identity

• Use aseptic technique to spike the bag and connect to the IV line

Infusion Pump:

• Program the pump according to medication order

• Monitor the infusion rate and patient response

Secondary Piggyback Set:

• Connect secondary set to primary IV line above the pump

• Ensure compatibility of medications in primary and secondary sets

Baseline Assessments for IV Therapy and Maintenance of Patency

• Baseline Assessments:

  • Assess patient’s medical history and current condition

  • Evaluate vein condition and select appropriate IV access device

• Maintenance of Patency:

  • Flush IV lines regularly with saline or heparin solution

    • “usually every 4 hours”

  • Monitor for signs of occlusion or infiltration

Complications Associated with IV Therapy: Phlebitis and Thrombophlebitis

• Signs and symptoms: Redness, swelling, pain along the vein

• Treatment: Discontinue IV line, apply warm compresses

• “Phlebitis is inflammation of a vein, while thrombophlebitis is inflammation caused by a blood clot (thrombus) in a vein”

Complications Associated with IV Therapy: Localized Infection and Septicemia

• Signs and symptoms:

  • Redness, swelling, pus at insertion site

  • Fever, chills, hypotension (septicemia)

• Treatment: Discontinue IV line, administer antibiotics

• “Septicemia is an infection that occurs when bacteria enter the bloodstream and spread”

Complications Associated with IV Therapy: Infiltration and Extravasation

• Signs and symptoms:

  • Swelling, coolness at insertion site

  • Tissue damage (extravasation)

• Treatment: Discontinue IV line, elevate extremity, apply warm compresses

• “Infiltration and extravasation both involve IV fluid leaking into surrounding tissue, but the key difference is the type of fluid: Infiltration is leakage of a non-irritating (non-vesicant) fluid (like saline), causing mild swelling and discomfort, while extravasation is leakage of a vesicant (tissue-damaging) substance (like chemotherapy), potentially leading to severe blistering, necrosis, and long-term injury, requiring specific antidotes”

Complications Associated with IV Therapy: Air in Tubing and Pulmonary Edema

• Signs and symptoms:

  • Shortness of breath, chest pain (air embolism)

  • Dyspnea, crackles (pulmonary edema)

• Treatment:

  • Clamp tubing, place patient on left side (air embolism)

  • Administer diuretics (pulmonary edema)

Complications Associated with IV Therapy: Catheter Embolism and Speed Shock

• Signs and symptoms:

  • Sudden pain at insertion site, shortness of breath (catheter embolism)

  • Dizziness, chest tightness (speed shock)

• Treatment:

  • Discontinue IV line, apply tourniquet above insertion site (catheter embolism)

  • Slow infusion rate (speed shock)

Common Challenges and Solutions in IV Therapy Administration: Challenge 1 - Ensuring Proper IV Placement

• Issue: Incorrect placement can lead to complications such as infiltration or phlebitis

• Solution: Use ultrasound guidance for difficult insertions, verify placement with imaging if necessary, and ensure proper training for staff

Common Challenges and Solutions in IV Therapy Administration: Challenge 2 - Maintaining IV Patency

• Issue: IV lines can become occluded, leading to interruption of therapy

• Solution: Regularly flush IV lines with saline or heparin solution, use positive pressure techniques, and monitor for signs of occlusion

Common Challenges and Solutions in IV Therapy Administration: Challenge 3 - Preventing Infections

• Issue: IV lines are a potential source of infection

• Solution: Use aseptic technique during insertion and maintenance, change dressings regularly, and monitor for signs of infection

Common Challenges and Solutions in IV Therapy Administration: Challenge 4 - Managing Patient Discomfort

• Issue: Patients may experience pain or discomfort at the IV site

• Solution: Use appropriate needle size, secure the IV line properly, and provide pain management as needed

Common Challenges and Solutions in IV Therapy Administration: Challenge 5 - Monitoring Fluid Balance

• Issue: Incorrect fluid administration can lead to fluid overload or dehydration

• Solution: Monitor intake and output closely, adjust fluid rates based on patient condition, and use infusion pumps for accurate delivery

Common Challenges and Solutions: Challenge 1 - Ensuring Proper Dosage

• Issue: Incorrect dosage can lead to ineffective treatment or adverse effects

• Solution: Double-check dosage calculations and use standardized measuring tools

Common Challenges and Solutions: Challenge 2 - Patient Non-Adherence

• Issue: Patients may forget or refuse to take medications as prescribed

• Solution: Educate patients on the importance of adherence and use reminders (e.g., pill organizers, alarms)

Common Challenges and Solutions: Challenge 3 - Managing Side Effects

• Issue: Patients may experience side effects that discourage them from continuing medication

• Solution: Monitor patients closely, provide information on managing side effects, and adjust treatment if necessary

Common Challenges and Solutions: Challenge 4 - Drug Interactions

• Issue: Medications may interact with other drugs, leading to adverse effects

• Solution: Review patient medication history, use drug interaction checkers, and consult with pharmacists

Common Challenges and Solutions: Challenge 5 - Administration Errors

• Issue: Errors in medication administration can occur due to various factors (e.g., distractions, lack of knowledge)

• Solution: Implement safety protocols, provide thorough training, and minimize distractions during administration

Best Practices in Pharmacology: Practice 1 - Accurate Documentation

• Importance: Ensures clear communication among healthcare providers and continuity of care

• Tips: Record all medication details accurately and promptly in patient records

Best Practices in Pharmacology: Practice 2 - Patient Education

• Importance: Empowers patients to manage their medications effectively

• Tips: Provide clear instructions, use teach-back methods, and offer written materials

Best Practices in Pharmacology: Practice 3 - Regular Monitoring and Follow-Up

• Importance: Detects issues early and ensures treatment efficacy

• Tips: Schedule regular follow-up appointments and monitor patient progress

Best Practices in Pharmacology: Practice 4 - Collaborative Care

• Importance: Enhances patient outcomes through a team-based approach

• Tips: Communicate regularly with other healthcare providers and involve patients in decision-making

Best Practices in Pharmacology: Practice 5 - Staying Informed

• Importance: Keeps healthcare providers updated on the latest pharmacology knowledge and practices

• Tips: Attend continuing education courses, read relevant literature, and participate in professional organizations